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Florida Heart Research Institute, 4770 Biscayne Blvd, Site 500, Miami, FL 33137
(Email: doctorwu18{at}aol.com).
Despite remarkable advances in interventional and medical therapy during the past 2 decades and a continuing decline in death, cardiovascular disease remains the leading killer in our country, and, increasingly, throughout the world. The current epidemic of obesity sadly promises to erase medical progress. Therefore the question of optimal treatment will remain a lively and hopefully productive debate for years to come.
Provocative studies such as Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) [1] have called into question the value of percutaneous coronary intervention (PCI) for patients with stable angina, whereas the data of Hannan and colleagues [2] reveal a long-term mortality benefit for coronary artery bypass grafting (CABG) vs PCI in the real-world setting of the New York State Cardiac Registry. It is in just this milieu of evolving medical, interventional, and surgical therapies that studies such as that presented by Aldea and colleagues [3] acquire added significance.
Tracking all patients undergoing CABG or PCI in the State of Washington between 1999 and 2007, the authors are able to provide clear documentation of changing practice patterns during the past decade. The trends reported for increasing PCI volume, decreasing CABG volume, and the rise and decline of drug-eluting stents and off-pump operations confirm recent reports of national trends. The finding that PCI does not appear to affect ejection fraction or mortality for subsequent CABG, although retrospective, is notable. Unfortunately, the database is limited to admission data; 30-day and long-term mortality rates, readmission rates, and reoperations for complications are all unknown.
Although the authors carefully track individual risk factors through different time periods according to presence or absence of previous PCI or CABG, what is lacking is a clear analysis of relative overall surgical risk over time. The sort of information that Ferguson and colleagues [4] so nicely demonstrated for the decade of the 1990s in the Society of Thoracic Surgeons (STS) population—increasing risk with declining mortality—is not discernible from the data presented. The surgical mortality rate was stable, and morbidity decreased; however, do these trends reflect changing referral patterns or improvements in surgical technique? Did risk factors specifically associated with mortality change over time, possibly reflecting improvements in surgical or medical care? Is there any identifiable pattern of risk factors that would suggest a better outcome for PCI vs CABG?
Based on the completeness of the data in a "real world" setting, the Aldea study is an important signpost in the rapidly evolving landscape of therapeutic interventions for coronary artery disease. As such, it raises more questions than it answers—questions that we hope will be addressed in forthcoming reports.
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